H&P: Viral Arthritis
- Symmetric Arthritis (MC: MCP, PIP, Wrist Joints)
- Acute Onset (differentiates it from RA)
- No elevated ESR
- Resolution w/in 2 mos.
Note: Adults who work with children
MCC: Viral Arthritis
Parvovirus B19
5H’s & T’s
H's: Hypovolemia Hypoxia Hypo-/Hyper-[K+] Hydrogen ions (acidosis) Hypothermia
T's Tension PTX Tamponade (Cardiac) Toxins (BZDs, Narcotics) Thrombosis (PE, Cardiac) Trauma
Early defibrillation is tx for what rhythms?
VFib
Pulseless VT
IV Lidocaine is used to tx what rhythm?
IV Lidocaine is a 2nd-line agent for HD stable monomorphic VT
Immediate synchronized electrical cardioversion is used in what rhythm?
- Symptomatic or sustained monomorphic VT (unresponsive to anti-arrhythmics)
- HD UNstable AFib with RVR
Pathologic Causes of Sinus Bradycardia?
- Sick Sinus Syndrome
- Myocardial ischemia/infarction
- OSA
- Hypothyroidism
- Increased ICP
- Medication overdose/overuse (i.e. Beta Blockers, CCBs…)
S/Sx of Symptomatic sinus bradycardia?
- fatigue
- dizziness
- light-headedness
- hypotension
- syncope
- angina
- CHF
S/Sx of Exertional Heat Stroke
- Core Body Temp > 40.5°C (105°F)
- Acute confusion
- Tachycardia
- Coagulopathic Bleeding
Criteria to ddx Toxic Megacolon
- Radiographic evidence of colonic dissension (>6cm)
PLUS at least 3 of the following:
- Fever >38°C
- HR > 120
- PMN Leukocytosis > 10,200/mL
- Anemia
PLUS at least 1 of the following:
- volume depletion
- Altered sensorium
- Electrolyte disturbances
- Hypotension
Initial test of choice for toxic megacolon
AXR
Will show Total Segmental Non-obstructive Colonic dilatation > 6cm
Management of Toxic Megacolon
Conservative: - Bowel Rest (NPO, NGT placement) - IF IBD (+): IV prednisone - IF Infection (+): ABx If no response or worsening condition: - Surgery: subtotal colectomy + end-ileostomy
Barium Enema in Toxic Megacolon - Good or bad?
BAD!
Barium enema is contraindicated in toxic megacolon due to concerns of colonic perforation
Causes of Toxic Megacolon
MCC: IBD (UC > Crohn’s Dx)
- ischemic colitis
- volvulus (children)
- diverticulitis
- infection (c. diff)
- Obstructive Colon CA (least common)
When are IBD patients at most risk for toxic megacolon?
First 3 years of disease
S/Sx of toxic megacolon
- Lower Abdominal Pain
- Severe Bloody Diarrhea
- Tenesmus
- Acutely worsening Systemic S/Sx c/w sepsis
Caustic Ingestion with Sodium Hydroxide (Lye):
- Clinical Features
Chemical Burn or liquefaction necrosis:
- Laryngeal damage: Hoarseness, stridor
- Esophageal damage: Dysphagia, odynophagia
- Gastric Damage: Epigastric pain, bleeding
Caustic ingestion with sodium hydroxide (lye):
- management
- ABCs
- Decontamination: remove clothing, chemicals, irrigate exposed skin
- CXR if reps. Sx
If HD stable: Early Endoscopy w/in 24hrs in patients w/o ARDS or perf.
If HD UNstable: Surgery (possible esophagectomy)
Caustic ingestion with sodium hydroxide (lye):
- Complications
- Upper airway compromise
- perforation (3-4 days s/p ingestion), can lead to mediastinitis. R/o with serial CXR & AXR
- strictures/ stenosis (2-3weeks)
- ulcers
- CA
If you suspect an upper GI perforation, what type of solution should you use to visualize the perf?
water-soluble contrast Upper GI XRay
Before SIADH is ddx, what two conditions should be r/o?
- Hypothyroidism
- Adrenal insufficiency
SIADH lab findings
Euvolemic Hypotonic Hyponatremia
Low sOsm: 100-150mOsm/kg) is diagnostic
Also: low BUN and normocytic anemia 2/2 hemodilution
SIADH is characterized by____?
persistently elevated ADH in the absence of hypertonicity.
most important treatment step in non-ketotic hyperglycemic coma is _____?
Other management steps include?
Fluid replacement with nml saline.
Step 1: 0.9% NS
Step 2: 0.45% 1/2 NS once hypovolemia is corrected.
Step 3: 5% Dextrose given once s[Glc]
